Prof. Dr. Şansın Tüzün
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Chronic musculoskeletal syndrome
characterized by diffuse pain and tender points
No evidence that synovitis or myositis are
causes
Occurs in the context of unrevealing physical
examination, labaratory and radiologic
examination
% 80-90 of patients are women, peak age is 3050 years
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Generalized chronic musculoskeletal pain
Diffuse tenderness at discrete anatomic
locations termed tender points
Other features, diagnostic utility but not
essential for classification of fibromyalgia are;
fatique, sleep disturbances, headaches, irritable
bowel syndrome, paresthesias, Raynaud’s-like
syndromes, depression and anxiety
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For classification criteria, patients must
have pain for at least 3 months involving
the upper and lower body, right and left
sides, as well as axial skeleton, and pain
at least 11 of 18 tender points on digital
examination
Syndrome
Relationship with
Fibromyalgia
Depression
Irritable bowel
Migraine
Chronic fatiqe
Syndrome
Myofascial pain
25-60 % of FM cases
50-80 % of FM cases
50 % of FM cases
70 % of CFS cases meet FM
May be localized form of FM
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Classify as CFS or idiopathic Chronic Fatique
if;
Fatique persists or relapse for > 6 months
History, physical examination and appropriate
laboratory tests exclude any other cause for the
chronic fatique
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Classify as CFS if along with fatique, four or
more of the following are present for >6
months;
Impaired memory of concentration, sore
throat, tender cervical or axillary lymph
nodes,muscle pain, multijoint pain, new
headaches ,unrefreshing sleep, postexertion
malaise
Presence of trigger points, which include a
localized area of deep muscle tenderness,
located in a taut band in the muscle, and
a characteristic reference zone of the
perceived pain that is aggravated by the
palpation of the trigger point
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Variable
Fibromyalgia
Myofascial
pain
Examination
Tender points
Trigger points
Location
Generalized
Regional
Response to
local therapy
Sex
Not sustained
Curative
Females;males
10:1
Equal
Systemic
features
characteristic
?
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NSAID
Tricyclic antidepresants ( i.e. amitriptyline,
desipramine 1-3h before bedtime)
Cardiovasculer fitness training
Biofeedback
Hypnotherapy
Cognitive behavioral therapy
Educating patient
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Results from incresed pressure on a nerve as it
passes through an enclosed space
Knowledge of anatomy is essential for
understanding of the clinical manifestations of
these syndromes
Splinting, NSAIDs and local corticosteroid
injections usually suffice when symptoms are mild
and of short time.
Surgical procedures to decompress the nerve are
indicated in more severe cases
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Results from compression of one or more of the
neurovasculer elements that pass through the
superior thoracic aperture
Anatomic abnormalities and trauma to the
shoulder girdle region play a far more pivotal
role
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Between the scalenius anterior and scalenius
medius
Costoclavicular space
Under the coracoid process and beneath the
pectoralis minor tendon
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Paresthesias
Aching pain, radiating to the neck, shoulder and
arm
Motor weakness
Atrophy of thenar, hypotenar and intrinsic
muscles of the hand
Vasomotor disturbances
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Neurologic examination
Certain clinical stress tests (Adson and
hyperabduction maneuvers)
A radiograph of cervicothoracic region
(cervical rib, elongated transverse process of
C7)
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Exercise designed to improve posture by
strengthening the rhomboid and trapezius
muscles
Avoidance of hyperabduction
Surgical intervention if; muscle wasting,
intermittent fleeting paresthesias replaced by
continous sensory loss, incapacitating
pain,worsening of circulatory impairment
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Compression neuropathy of the ulnar nerve as
it transverses the elbow
Causes are; history of a trauma, chronic
pressure by occupational stress or from
unusual elbow positioning
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Arthritic conditions that results in synovitis
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Osteophyte production
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Paresthesias in the distribution of the ulnar nerve
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Aggrevated by prolonged use of the elbow in
flexed position
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(+) Tinel’s sign
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Atrophy of intrinsic muscles and weakness in
pinch and grasp
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Wasting of the hypothenar muscles and slight
clawing of the 4th and 5th fingers
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Weakness in adduction of the 5th finger
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Physical examination (Tinel’s sign,
Wartenberg’s sign i.e.)
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Radiographs
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Electrodiagnosis
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Avoidance of prolonged elbow flexion
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Local steroid injection along the ulnar groove
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Surgical procedures to decompress the nerve
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Entrapment of the ulnar nerve in Guyon’s
canal at the wrist
Compression is due to ganglia
Causes are; Aberrant muscles, Dupuytren’s
disease, RA, OA
Chronic trauma due to certain tools and
occupations
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Combined sensory and motor deficits
Hypoesthesia in the hypothenar region and 4th
and 5th fingers
Weakness of the intrinsic muscles of the hand
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Pyhsical examination
Electrodiagnosis is helpful in determining the site
of the entrapmant
Treatment
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Avoidance of trauma
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Physical therapy
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Surgical decompression
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Most common entrapment neuroropathy
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Compression of the median nerve at the wrist
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Causes are; occupation, crystal-induced rheumatic
disorders
Complication of connective tissue disorders
Uremia, metabolic and endocrine diseases,
infections, familial occurrance, during pregnancy
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Sensory loss in the radial three finger and onehalf of the ring finger
Burning, pins-and-needles sensations,
numbness and tingling in the fingers
Pain may radiate to the antecubital region or to
the lateral shoulder area
Awaken at night by abnormal sensation
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(+)Tinel’s sign
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(+) Phalen’s sign (wrist flexion)
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Thenar atrophy
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History and physical examination
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Radiographs
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Electrodiagnosis
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Splints
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Local corticosteroid injection
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NSAIDs
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Physical therapy
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Surgery ; patients with progressive increases in
distal motor latency times